Unsecured Medications Observed on Units with Cognitively Impaired Residents
Penalty
Summary
Surveyors observed that the facility failed to properly secure medications on two separate nursing units. On one occasion, a medicine cup containing a clear liquid was left unattended on top of a medication cart in a secure dementia unit. Two residents with documented severe cognitive deficits and wandering behaviors were present in the immediate area, and no staff were observed nearby at the time. The medication cart was later identified as belonging to an RN, who confirmed the medication was for another resident. In a separate incident, a blister pack containing 28 tablets of an antibiotic was found unattended at a nursing station desk. The medication was intended for a resident and had been separated for different halls, but was not secured in the appropriate medication cart. The medication remained unattended until a staff RN was questioned and subsequently secured the medication. Both incidents involved residents with significant cognitive impairments and occurred in areas where staff were not present to supervise the medications.